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Pelvic Ring Injuries Renée Genova, MD

Assistant Professor

29th Annual Decisions in Trauma Conference

May 9th, 2019

Springfield, Missouri

5 pm

Saturday afternoon

Call goes out for a MCC on US Route 65

26 y.o male rider lying on highway

50 feet from his motorcycle

Scenario

Scenario32 year old male wearing helmet and protective gear.

Conscious

Confused

Slightly Tachypneic

Tachycardiac

BP: 90/50

Palpable radial pulse

No blood at the scene

Complains of low back and ‘hip’ pain

Next Steps

Large bore IV placed

Transport to the nearest level one trauma center

BP responds transiently to 1L Crystalloid

117/70, then down to 80/60 with HR: 110

What Next?

Which Way?

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Next Steps

�Administer Crystalloid

� Patient does not respond

� Initiate MTP

� Transient response

�ATLS protocolNo xrays

� Patient sent to CT scanner

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Rapid Response in CT Scanner

�Blood pressures drop further, patient becomes tachycardicto 150s and is un responsive.

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AP pelvis

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AP pelvis xray would have demonstrated this injury

Pelvic Ring Disruption

Marker for severe injury

Overall mortality 6-10%

Life threatening

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Magnitude of Forces

�ACL injury 500-1000N

� LC-I pelvic fracture 6000-9000N

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Pelvis Anatomy

�Pelvis protects many important structures

�Visceral anatomy at risk for injury

Pelvic Ring Disruption

�Significant force sustained

�HemorrhageoPrimary cause of early death

oMany large blood vessels within the pelvis

�VENOUS

�ARTERIAL

�OSSEOUS

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Initial Management of Pelvic Ring Injury

Airway maintenance with cervical spine protection

Breathing and ventilation

Circulation with hemorrhage control

Disability: Neurologic status

Exposure/environment control: undress patient but prevent hypothemia

Patient Assessment

1. Neurovascular assessment of BLE

2. Skin inspection- evaluate for open wounds

3. Inspect flank and perineum for contusions/ecchymosis

4. Evaluate for urogenital injuriesScrotal edema, blood at urethral meatus or vaginal canal

5. Rectal exam to rule out open communication of rectal mucosa with fracture

Back to our Scenario: Which Way?

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Initial Management of Pelvic Ring Injury

� IV access

�Fluid Resuscitation

�Application of pelvic binder

�Xray AP Pelvis

Hemorrhage

Increased volume

Hemorrhage

Increased volume

Pelvic Binder

Pelvic BinderPelvic Ring Injuries

Hemorrhage fills the true pelvis as

there is no longer a constraint

which allows tamponade.

The volume best represented by a

hemi-elliptical sphere

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Pelvic Binder Circumferential Sheet

Binder: Appropriate Placement�Centered over the Greater Trochanters

� Internally rotate legs at the knees

“Open Book”

After Pelvic BinderRole of Angiography???

� Valuable for arterial only

� Estimated at 5-15%

� Timing (early vs late?)

� Institution dependent

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Pelvic Packing

� Ertel, W et al, JOT, 2001

� Pohlemann et al, Giannoudis et al,

Type of Injury

26

0.

10.

20.

30.

40.

LC-I LC-II LC-III VS AP-II AP-III

2.3 3.1

7.49.4

7.6

35.4

units blood

1st 24 hours

RESUSCITATION REQUIREMENTSSummary: Acute Management

� ATLS

� Radiographs

� Resuscitation

� Do something (sheet, binder, ex fix, c-clamp)

� Combine knowledge of the fracture, the patients condition, and the physical exam to decide on the next step

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